Sunday, 21 March 2010

Overdose

Hi,

Quite a varied week this week, but I would like to just talk about a couple of the more outstanding patients, as they were the most memorable. Two of these patients were
1)someone who came in via A&E who had taken just shy of 100 paracetamol tablets the previous day, and
2) I saw someone who had gotten some complications, possibly related to a nasty and rare form of cancer he had.
I was also disgusted by one of my fellow medical student's viewpoints as to transplantation in 'those who don't deserve it' which made me pretty disappointed in someone whom I had previously thought was a caring and intelligent individual. Not that I want to rant or anything, there are plenty of medical blogs out there that do that sufficiently!

Anyway, when I went onto my on call this week, as soon as I got there I was told by the consultant that they had a patient for me to see, and had just sent another medical student (my partner) over to talk to them. I was told it was an overdose, but that was all. I arrived a tad after my partner had started talking to the patient, and had the embarrassing part of slipping through the privacy curtains and introducing myself whilst trying to look professional (don't think I pulled it off though). We talked to the patient for some time, getting the important information of how many paracetamol he had taken, how long ago it was and whether he had taken any other drugs with these (more drugs, including alcohol, makes for a worse outcome). It turned out that he had taken just under 100 paracetamol the day before, then locked himself into his room and fallen asleep. 14 hours later his mum (he was my age) had realised he had been in his room for some time and had ended up pushing the door down to find him asleep. Having woken him up and fond what he had done, the ambulance was called and bought him to us.

There is a set treatment regime for this common overdose, and associated graphs and literature easily found in the A&E setting. This treatment regime involves giving a drug called N-acetylcysteine (NAC). Paracetamol needs a certain substance in the body to help its normal breakdown. If this substance runs out (I.e. if too much paracetamol is taken) then paracetamol is broken down to a different substance which is TOXIC. The treatment for paracetamol overdose involves putting into the body more of this substance, so it doesn't run out, and all of the paracetamol is broken down normally. The toxic substance it is otherwise broken down to can ruin the liver and kidneys. The problem with this treatment is that it needs to be given relativity soon after the paracetamol overdose as otherwise the paracetamol gets broken down to this toxic metabolite and damages the liver and kidneys.

Because the patient had hidden his overdose, this was the situation we were faced with. It had been too long since he had taken the pills for the treatment to be likely to work, but it is possible is would help, so he was put on the NAC as soon as possible. We talked to him some more about his reasons for wanting to commit suicide as it seemed like he had really intended to kill himself, locking himself away, not leaving a trail, taking a very large number of tablets (I would have personally got bored half way through taking that many pills and given up). Anyway - I won't talk about his personal situation but being the same age as me he had had a lot of things happen to him in is life that were not fair, and people shouldn't have to go through. Previous suicide attempts seemed to have been brushed off by the healthcare system and he felt ignored and uncared for. As medical students talking to him we were pretty much helpless. What were we meant to say? "Don't worry, its not all that bad. Sorry to hear you want to kill yourself, perhaps you will feel better next week?" We could just offer a kind ear until his sister showed up and we left them in peace for a bit.

As for the treatment of paracetamol overdose, the treatment of the person is decided on the amount of paracetamol in their blood stream. If it is very low then treatment is not carried out, as it is not high enough to be toxic. A graph like the one below is used.

The amount of paracetamol in the blood is measured and plotted against the time since it was taken (the levels go down over time, as the body breaks it down, so the time the pills were taken is very important). In a 'normal' patient, if the point this makes on the graph is above the 'normal treatment line' the patient needs NAC as the paracetamol levels in the blood were too high. This patient had a point much too high in the blood (I.e. around the letter A) so needed the treatment. If the patient has some damage already to their liver, or took the paracetamol with other drugs such as alcohol, then they should be below the 'enhanced risk' line to avoid treatment, other wise they will need the NAC. For instance, if a patient had taken 5 paracetamol and came in with a level around where the letter B is they would not need the NAC, as they are at no risk of organ damage. Anyway, our patient definitely needed treatment, and blood tests showed that the liver was already damaged, and the kidneys were functioning poorly. The patient was not urinating much, and when he did it was brown thick liquid. Not good.

To cut the story short, after a day on the treatment, it was decided that this poor bloke needed a liver transplant as the liver was failing. An organ your body cannot do without and, unlike the kidneys with dialysis, there is no artificial support method for a damaged liver. Either he will get a liver transplant in time, or he will die. Pretty shocking news for his family.

A couple of days after seeing this patient, myself and the other 5 students on my firm were discussing some of the patients we had seen that week. Most of us had met the same patients, but had all spent varying time with each one, so talking about the patients with each other lets us learn more. I was talking to my colleges about the patient who had come in with a paracetamol overdose, and the fact that he will now need a new liver. One of my colleges, a nice friendly girl, usually with a smile on her face, goes and drops a bombshell of a reply.

"Why give him a new liver? He destroyed his old one. What a waste!"

You are joking, right? All those years of boring ethics lectures and you can pop out a comment like that?

No, she wasn't joking. She genuinely and honestly thought that because this patient had damaged himself and destroyed his own liver he shouldn't be allowed a new liver and should instead be left to die. What about ex-alcoholics who need new livers? What about people involved in car accidents where they were exceeding the speed limit? What about people who decide to smoke and end up with lung cancer? What about people who eat too much, get fat and end up having a heart attack? Nope! They don't deserve our treatment because they did this to themselves!

Its quite simple. Mental illness is a disease, just like having a broken leg or a stroke. With the right management, care, and support into turning his life around this person will not remain suicidal for the rest of his life. Just because he was ill enough to think that suicide was the only way out of the situation he was in, does that mean you just want to go and kill him for it?

Anyway, I will not rant for too long on this case. It was just amazing to see someone who seemed like a nicely balanced, friendly person with a decent ethical education rain down judgement on someone whose life was so different from hers that she must have no idea of how he felt. How can you look down on someone who decided to take their life after all of these bad things happen if you haven't had them happen to you? How does this medical student know that if half these things had happened to her she wouldn't have gotten upset and tried something similar. And then how would she like to be told, once she was in a better place mentally, that she would be left to die because she had done this to herself. It is beyond belief. Anyway - I really hope that the next few years bring this eduction to those who need it on the course. I hope there are not that many third year medical students and upwards who would think like this.

Anyway, I wasn't that outspokenly offended by her - I showed my distaste (I think I might have used disappointment rather than distaste) in her views, but I have to spend time with her and don't want her to think that I am a massive morally righteous douche-bag so I kept it calm, but kind of regret that now.

So as not to end on a negative note I will mention one of the other patients I saw this week. A 35odd year old man presented to the A&E with massive abdominal pain and vomiting. A lot of vomiting. As in he had been vomiting almost continuously since about 8 hours ago that morning and had managed to get through 4 buckets since he had gotten to A&E. He had a complicated history of a rare multifocal cancer (a cancer that appears in multiple places in the body). Like any good medical professionals, when we heard about this we and the F1 had a good old google/Wikipedia search to find out a bit about this. With the amount of odd rare disorders there are out there, doctors cannot know a lot about everything, unfortunately, and while each of them is rare or Very rare, there are a lot of them out there, so you will see some every now and then! Anyway - this was a very complicated case. We were unable to even examine his abdomen because of the amount of pain he was in, doubled over and clutching himself. Was it the cancer causing his vomiting and pain? Was there new obstruction from a growth? Was it the chemo he was on disagreeing with him suddenly (less likely) or was it a completely new diagnosis unrelated to the cancer? I don't know yet either! I hope to find out on Monday though. Anyway, the main reason for bothering to point that out was the complexity that some cases can come in with. I find it hard to imagine being a consultant and having ultimate responsibility over such cases. No-one knows what is causing pain/vomiting/any symptom and the patient is on your ward. If you don't find out, they may die. Scary! All of that trust and the absurd amount of knowledge you must need if you are a speciality consultant! Perhaps I will become a GP after all, so I can just refer on the really complex stuff!

Another busy week, so another poorly put together blog. As the year goes on I am sure they will get worse and worse, but I am afraid you will have to live with it, or give me an extra couple of hours a day! Then I might be able to get the work done I need to as well!

8 comments:

Thanks for your comment and good wishes. I'm quite jealous of your hands-on experience (except dealing with suicidal patients - that's going to be tough). I'm still four months from being in the hospitals. It's good to read about the cases you find noteworthy, so I look forward to more.

Very interesting debate over the whole 'who deserves the organ' issue. I remember having a very similar argument during my PBL sessions. I was, however, probably tipping towards your collegue's side of thinking - all be it she seems to have taken it to an extreme. It must be considered (and this is very much a reality of medicine) that such organs are certainly not plentiful. To whom would you give the one remaining liver if you were faced with the same gentleman you saw and a young, similar aged girl who had been hit by a drunk driver? Perhaps she was not saying that he did not deserve the organ, more that if it came down to a decision on limited supply, it would be difficult to make such a cut and dry case. There are people who need to make these decisions in medicine, and it comes down to who is likely to look after their organ, and have more QALYs with it.

@anonymous Idepression due to atlered brain biochemistry, lack of certain neurotransmitters, is a recognized disease like diabetes is recognized as a disease if you want.the decision who would get the liver should not be based on how the liver damage occured but on who was put on the transplant list first.

Sorry Anonymous but that is utter nonsense! The decision as to who gets organs/treatment is one based on factors such as clinical need, risk, chances of success, rejection, complications etc, not a decision made on humanistic merit of whom is more "deserving". Your line of thinking sets a very dangerous and worrying precedent. It is about medical factors, not the moral judgments of others, as to how patients are treated.

Now, back to the blog and the issues so rightfully and professionally highlighted. This poor suicidal chap is clearly mentally ill. It is obvious from his previous suicide attempts and the lack of assistance and treatment that the healthcare system has failed him, spectacularly so. Unfortunately, the NHS is notoriously bad at acute intervention and there is a known issue with diabolical provision of chronic Mental Health services. Had this unfortunate chap been assisted properly in a timely manner, he would, on the balance of probabilities, not have again tried to commit suicide, or would have been under appropriate supervision, nor would he have the means to do so - as he should have been sectioned after the first attempt, or first expression of suicidal ideation.

As to the medical student deciding to take the moral highground over a mentally ill patient, that student has the wrong attitude entirely for a career in medicine and has no place on a medical course, let alone being anywhere near a hospital. A trainee clinician surmising over whom should and shouldn't be entitled to healthcare is utterly scandalous - healthcare as per the gambit of the NHS is available "at the point of need" and no clinician is in any position to judge, nor provide or deny healthcare based on their own moral prejudices, in line with the Hippocratic oath.

Frankly, one can appreciate the fact that you have to see this student regularly, however, whether or not one wishes not to be seen as morally righteous, on balance, the need to correct this terribly inappropriate perspective is of far more importance than the need to avoid looking like a "douchebag". It is imperative that viewpoints like this are not fostered within the NHS and that colleagues expressing such views are immediately informed that those kind of views are repugnant, unprofessional, unethical and essentially tantamount to gross negligence and give rise to possible criminal implications, should they influence patient care.

Refusing a clearly mentally ill patient, whom has already patently been failed by the healthcare system, a liver, (and indeed leaving him to die, when the possibility exists that he can be saved), on the grounds that in the clinician's view, his medical condition is "self-inflicted," is expressing the intention to kill someone (by omission or inaction) and would potentially fulfil the criminal elements (mens rea etc) needed to satisfy a murder charge at worst and at best, a charge of manslaughter. This point should have been been made abundantly clear by her peers and/or lecturers. In fact, I will go out on a limb, that student should be asked to leave the course for gross misconduct.

I feel that this issue warrants immediate action and that the student in question should be reported and appropriate action taken. One cannot, in all good moral conscience, simply stand back and and let this utterly reprehensible behaviour go unchallenged.

Ah, I apologise. I wholeheartedly agree with you, yes this gentleman does deserve the liver every bit as much as anyone else, as he has a medical illness, I never meant to make that part of the argument, but reading over it, it does seem as though I was condoning discrimination.

My argument was not on what should be done, merely on how people's views differ in the interest of debate. I doubt if you asked this girl what she actually would do, that she would refuse the gentleman the liver. It says in the guidelines for duties of a doctor that a doctor should "never discriminate against patients". It mentions nowhere that doctors are not allowed their own beliefs. There are many doctors who disagree with abortion, even if it is in the patient's best interest. I think, rather than stifle these opinions, it is far more important to address them - I find it far more dangerous to assume I will never have conflicts of conscience such as this girl, rather than learn how to deal with them early on. It is all part of the learning process. Rather than reporting her, I would discuss with her whether that was merely her belief, or what she would genuinely do - they are two very seperate things.

Nice to see some healthy debate going on here, and thanks for posting up your views and replies. I am glad people agree with me and I am not just airing my feelings of righteousness to a load of people who disagree.

If the topic is raised again, yes I would jump at the chance to engage this individual in a proper discussion, but I think it is unlikely that I will pounce on her and start ripping her apart...

Don't worry about the multiple posts Anonymous, I will delete a few of them!